Office of Billing Compliance 2014 Professional Coding, Billing and Documentation Program

Prepared by:

Medical Compliance Services, Miller School of Medicine/University of Miami and Compliance Concepts, Inc.

Office of Billing Compliance

2014 Professional Coding, Billing and

Documentation Program

What is a Compliance Program?



A centralized process to promote honest, ethical behavior in the

day-to-day operations of an organization, which will allow the

organization to identify, correct, and prevent illegal conduct.



It is a system of: FIND – FIX – PREVENT

The University of Miami implemented the Billing Compliance Plan on November 12, 1996. The components of the Compliance Plan are:

1. Policies and Procedures

2. Having a Compliance Officer and Compliance Committees 3. Effective Training and Education

4. Effective Lines of Communication (1-877-415-4357 or 305-243-5842) 5. Disciplinary Guidelines

Auditing and Monitoring

The Government



In order to address fraud and abuse in the Healthcare Field, the

government has on-going reviews and investigations nationally

to detect any actual or perceived waste and abuse.



The Government does believe that the majority of Healthcare

providers deliver quality care and submit accurate claims.

However, the amount of money in the healthcare system, makes

it a prime target for fraud and abuse.

Centers for Medicare and Medicaid Services (CMS) Estimates > $50 Billion In

“Payment Errors” Annually in Healthcare

Health Care Laws

There are five important health care laws that have a significant

impact on how we conduct business:



False Claims Act



Health Care Fraud Statute



Anti-Kickback Statute



Stark Law



Sunshine Act



Requires manufacturers of drugs, medical devices and biologicals

that participate in U.S. federal health care programs to report

certain payments and items of value >$10 given to physicians and

False Claims Act :

What is a False Claim?



A false claim is the knowing submission of a false or fraudulent

claim for payment or approval or the use of a false record that is

material to a false claim.

OR



Reckless disregard of the truth or an attempt to remain ignorant

of billing requirements are also considered violations of the

False Claims Act.

This certification forms the basis for a false claim.

How do you create a False Claim?

MEDICAL NECESSITY

Quality & Cost:

Quality & Cost: Emphasis on Pay-for-

Performance PQRS & Meaningful Use



Practitioner reimbursement will likely be tied to outcomes soon.



Some experts say that the CMS penalties for not participating in

the Physician Quality Reporting System (PQRS) signal that the

pay-for-performance trend is not fading away and will likely will be

adopted by private payers.



“I think we’re slowly transitioning out of fee-for-service and into a

system that rewards for quality while controlling cost,” says

Miranda Franco, government affairs representative for the Medical

Group Management Association. “The intent of CMS is to have

physicians moving toward capturing quality data and improving

metrics on [them].”

Audits are being conducted for all payer types based

on the medical necessity of procedures and E/M

levels. Procedure are often linked to diagnosis codes

and the E/M audits are generally expressed in two

ways in conjunction with the needs of the patient:

•

Frequency of services (how often the patients

are being seen) and,

•

Intensity of service (level of CPT code billed).

Medical Necessity for E/M Services

Elements of Medical Necessity



CMS’s determination of medical necessity is

separate from its determination that the E/M

service was rendered as billed.



Complexity of documented co-morbidities that

clearly influenced physician work.



Physical scope encompassed by the problems

(number of physical systems affected by the

problems).

Referring Page: http://www.cgsmedicare.com/kyb/coverage/mr/articles/em_volume.html

November 2012

E/M Coding: Volume of Documentation versus Medical Necessity

•

Word processing software, the electronic medical record, and

formatted note systems facilitate the "carry over" and repetitive "fill in"

of stored information.

•

Even if a "complete" note is generated, only the medically reasonable

and necessary services for the condition of the particular patient at the

time of the encounter as documented can be considered when

selecting the appropriate level of an E/M service.

•

Information that has no pertinence to the patient's situation at that

specific time cannot be counted.

Office of

the

Inspector

General (OIG) Audit Focus

Annually OIG publishes it "targets" for the upcoming year.

Included is:



Cutting and Pasting Documentation in the EMR

REMEMBER: More volume is not always better in the

medical record, especially in the EMR with potential for

cutting/pasting, copy forward, pre-defined templates and

pre-defined E/M fields. Ensure the billed code is reflective

of the service provided on the DOS.

Medical Record

Documentation Standards

Pre EMR:

“If it isn’t documented, it hasn’t been done.”

- Unknown

Post EMR: “If it was documented, was it

done and was it medically necessary to

do.”

EMR Documentation Pitfalls



On reviews, the following are targets to call into question

EMR documentation is original and accurate:



HPI and ROS don’t agree



HPI and PE don’t agree



CC is not addressed in the PE



ROS and PFSH complete on every visit



ROS all negative when patient coming for a CC



Identical documentation across services (cloning)



The lack of or Inappropriate Teaching Physician

Top Procedure Codes Billed in Q4 2013

Top 5 E&M Description %

99232 SUBSEQUENT HOSPITAL 24% 99213 OFFICE/OUTPT 21% 99231 SUBSEQUENT HOSPITAL 16% 99214 OFFICE/OUTPT 9% 99223 INITIAL HOSPITAL 6% All other E/M Codes 24% Top 5 Procedure Description %

90834 PSYCHOTHERAPY PATIENT &/ FAMILY 45 MINUTES 17% 96118 PSYCH/NEUROPSYCH TESTS 2% 90791 PSYCHIATRIC DIAGNOSTIC EVAL 2% 90792

PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL

SERVICES 2%

90870 ELECTROCONVULSIVE THERAPY,1 SEIZ 2% All other

Procedure

National CMS Data For Speciality E/M

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

National CMS Data For Speciality E/M

Evaluation and Management E/M

Documentation and Coding

New vs Established Patient for E/M

Outpatient Office and Preventive Medicine

https://questions.cms.gov/faq.php?id=5005&faqId=1969

What is the definition of "new patient" for billing E/M services?



“New patient" is a patient who has not received any professional services,

i.e., E/M service or other face-to-face service (e.g., Procedure) from the

same physician or another physician in the same group practice (same

group NPI# and physician specialty) within the previous three years.



An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the

absence of an E/M service or other face-to-face service with the patient

does not affect the designation of a new patient.



In 2012, the AMA CPT instructions for billing new patient visits include

physicians in the same specialty and subspecialty. However, for Medicare

E/M services the same specialty is determined by the physician's or

E/M Key Components

History (HX)-

Subjective information

Examination (PE)-

Objective information

Medical Decision Making (MDM)-

Linked

to medical necessity

The billable service is determined by the combination of these 3

key components with MDM often linked to medical necessity. For

new patients all 3 components must be

met or exceeded

and

established patient visits 2 of 3 are required to be

met or exceeded

.

Often when downcoded for medical necessity it is determined

that documented History and Exam exceeded what was necessary

for the visit.

Elements of an E/M History



The extent of information gathered for history is

dependent upon clinical judgment and nature of the

presenting problem. Documentation of the patient’s

history includes some or all of the following elements:



Chief Complaint (CC) & History of Present

Illness (HPI)



WHY IS THE PATIENT BEING SEEN TODAY



Review of Systems (ROS),

H

istory of

P

resent

I

llness (

HPI

)

A KEY to Support Medical Necessity to

in addition to MDM

Chronological description of the patient’s present illness from the

first sign/symptom or from the previous encounter to the present.



HPI: Current symptoms, depression/mania/psychosis

screen, safety, compliance, stressors, ETOH/Drugs (inc

w/d)



HPI drivers:



Extent of PFSH, ROS and physical exam performed



Medical necessity for amount work performed and

documented & Medical necessity for E & M

assignment

22 The HPI must be performed and documented by the billing

provider for New Patients in order to be counted towards the New Patient level of service billed.

Review of Systems (ROS)

•

1 ROS documented = Pertinent

•

2-9 ROS documented = Extended

•

10 + = Complete

(or documentation of pertinent positive

and negative ROS and a notation “all others negative”. This

would indicate all 14 ROS were performed and would be

complete.)

Record positives and pertinent negatives.

Never note the system(s) related to the presenting problem as

"negative".

When using "negative" notation, always identify which systems

were queried and found to be negative.

Past, Family, and/or Social History



Past History includes illnesses, operations, injuries or

treatments : (remember to ask about TBI)



Family history includes a review of medical events, :

mental illness, substance abuse, suicide



Social history includes an age-appropriate review of past

and current activities (e.g., smoking, marital status,

employment status, education, income/employment/

disability, living situation, marriage/partner/kids, legal, hx

trauma/abuse.)

Record Past/Family/Social History (PFSH) appropriately considering the clinical circumstance of the encounter. Extensive PFSH is unnecessary for lower-level services.

Psychiatric 1997 EXAMINATION



4 TYPES OF EXAMS



Problem focused (PF)



Expanded problem focused (EPF)



Detailed (D)



Comprehensive (C)



Axis I. Psychiatric d/o including Substance abuse



Axis II. Personality d/o and developmental disorders

Axis III. Medical Problems

PSYCH Examination

Constitutional

 Measurement of any three of the following seven vital signs: 1) sitting or standing

blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff)

 General appearance of patient (eg, development, nutrition, body habitus, deformities,

attention to grooming)

MS

Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic) with notation of any atrophy and abnormal movements

Examination of gait and station

Psychiatric

Description of speech including: rate; volume; articulation; coherence; and spontaneity with notation of abnormalities (eg, perseveration, paucity of language)

 Description of thought processes including: rate of thoughts; content of thoughts (eg,

logical vs. illogical, tangential); abstract reasoning; and computation

 Description of associations (eg, loose, tangential, circumstantial, intact)

 Description of abnormal or psychotic thoughts including: hallucinations; delusions;

preoccupation with violence; homicidal or suicidal ideation; and obsessions

 Description of the patient’s judgment (eg, concerning everyday activities and social

situations) and insight (eg, concerning psychiatric condition) Complete mental status examination including:

 Orientation to time, place and person

Recent and remote memory

Attention span and concentration

 Language (eg, naming objects, repeating phrases)

 Fund of knowledge (eg, awareness of current events, past history, vocabulary)

1997 Exam Definitions

Problem Focused (PF)

• ‘97=Specialty and GMS: 1-5 elements identified by bullet

Expanded Problem Focused (EPF)

• ‘97=Specialty and GMS: At least 6 elements identified by bullet.

Detailed (D)

• 97=Specialty: At least 9 elements identified by bullet for psyc

Comprehensive (C)

• ‘97=Specialty: All elements with bullet in shaded areas and at least 1 in

non-shaded area.

Medical Decision Making

DOCUMENT EVERYTHING THAT EFFECTS YOUR SERVICE!!

• Number of possible diagnosis and/or the number of management options.

Step 1:

• Amount and/or complexity of data reviewed, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed.

Step 2:

• The risk of significant complications, morbidity, and/or mortality with the patient’s problem(s), diagnostic procedure(s), and/or possible

management options.

Step 3:

Exchange of clinically reasonable and necessary information and the

use of this information in the clinical management of the patient

MDM Step 1

Number of Diagnosis or Treatment Options –

Identify Each That Effects Patient Care For The DOS

Problem(s) Status

Number Points Results

Self-limited or minor

(stable, improved or worsening)

Max=2

1

Est. Problem (to examiner) stable,

improved

1

Est. Problem (to examiner) worsening

2

New problem (to examiner); no

additional workup planned

Max=1

3

New prob. (To examiner); additional

workup planned

4

MDM Step 2

Total the points

REVIEWED DATA Points Review and/or order of clinical lab tests 1 Review and/or order of tests in the radiology section of CPT 1 Review and/or order of tests in the medicine section of CPT 1 Discussion of test results with performing physician 1 Decision to obtain old records and/or obtain history from

someone other than patient 1 Review and summarization of old records and/or obtaining

history from someone other than patient and/or discussion of case with another health care provider

2

Independent visualization of image, tracing or specimen itself (not simply review of report).

MDM Step 3: Risk



The risk of significant complications, morbidity, and/or

mortality is based on the risks associated with the presenting

problem(s), the diagnostic procedure(s), and the possible

management options.

 DG: Comorbidities/underlying diseases or other factors that increase

the complexity of medical decision making by increasing the risk of complications, morbidity, and/or mortality should be documented.



Risk is assessed based on the risk to the patient between

present visit and the NEXT time the patient will be seen by

billing provider or risk for planned intervention

MDM – Step 3: Risk

Presenting Problem Diagnostic Procedure(s)

Ordered Management Options Selected

Min • One self-limited / minor

problem •• Labs requiring venipuncture CXR EKG/ECG UA

• Rest Elastic bandages Gargles Superficial dressings

Low • 2 or more self-limited/minor problems

• 1 stable chronic illness (controlled HTN)

• Acute uncomplicated illness / injury (simple sprain)

• Physiologic tests not under stress (PFT)

• Non-CV imaging studies (barium enema)

• Superficial needle biopsies • Labs requiring arterial puncture • Skin biopsies

• OTC meds

• Minor surgery w/no identified risk factors

• PT, OT

• IV fluids w/out additives

Mod • 1 > chronic illness, mod. Exacerbation, progression or side effects of treatment • 2 or more chronic illnesses • Undiagnosed new problem

w/uncertain prognosis • Acute illness w/systemic

symptoms (colitis)

• Acute complicated injury

• Physiologic tests under stress (stress test)

• Diagnostic endoscopies w/out risk factors

• Deep incisional biopsies

• CV imaging w/contrast, no risk factors (arteriogram, cardiac cath)

• Obtain fluid from body cavity (lumbar puncture)

• Prescription meds

• Minor surgery w/identified risk factors

• Elective major surgery w/out risk factors

• Therapeutic nuclear medicine • IV fluids w/additives

• Closed treatment, FX /

dislocation w/out manipulation

High • 1 > chronic illness, severe

exacerbation, progression or side effects of treatment • Acute or chronic illnesses

that may pose threat to life or bodily function (acute MI)

• CV imaging w/contrast, w/risk factors

• Cardiac electrophysiological tests

• Diagnostic endoscopies w/risk factors

• Elective major surgery w/risk factors

• Emergency surgery • Parenteral controlled

substances

Draw a line down any column with 2 or 3 circles to identify the type of decision making in that column. Otherwise, draw a line down the column with the 2nd _{circle from the left. After}

completing this table, which classifies complexity, circle the type of decision making within the appropriate grid.

Final Result for Complexity

A Number diagnoses or treatment options < 1 Minimal 2 Limited 3 Multiple > 4 Extensive

B Highest Risk Minimal Low Moderate High

C Amount and complexity of data < 1 Minimal or low 2 Limited 3 Multiple > 4 Extensive

Type of decision making

STRAIGHT-FORWARD LOW COMPLEX. MODERATE COMPLEX. HIGH COMPLEX.

USING DIFFERENT LEVELS OF CARE

Using Time to Code

Time shall be considered for coding an E/M level when

greater than 50% of total

Teaching Physician

visit time is

Counseling /Coordinating Care –

Total time must be Face-to-face for OP and floor time /

face-to-face for IP

What Is Counseling /Coordinating

Care (CCC)?

A Discussion of:

 Diagnostic results, impressions,

and/or recommended studies

 Prognosis

 Risks and benefits of management

 Instructions for treatment and/or follow-up  Importance of compliance

Required Documentation:

 Total time of the encounter

 The amount of time dedicated to counseling / coordination of care  The nature of counseling/coordination of care

John Doe MR# 11122234 D.O.S. 9/15/014

Patient counseled regarding health risk, contraceptives, exercise, and usage of medication. Counseling Time: 20min. Total Encounter Time: 30 min.

Working With NP's and PA's (NPP's)

The NP or PA MUST BE AN EMPLOYEE OF THE PRACTICE AND

CANNOT BE A HOSPITAL EMPLOYEE TO UTILIZE ANY OF THEIR

DOCUMENTATION FOR PHYSICIAN BILLING AS SHARED



Shared visit with an NPP may be billed under the physician's name

only if:



The physician provides a face-to-face portion of the visit and

The physician personally documents in the patient's record the

portion of the E/M encounter with the patient they provided.



If the physician does not personally perform or personally and

contemporaneously document their face-to-face portion of the E/M

encounter with the patient, then the E/M encounter may only be

billed under the PA/ARNP's name and provider number



Procedures must be billed under the performing provider & not the

Guidelines for Teaching

Physicians, Interns, Residents and

Fellows

For Billing Services, All Types of Services Involving a Teaching

Physician (TP) Requires Attestations In EHR or Paper Charts

Evaluation and Management (E/M)

IP or OP:

TP must

personally document

at least the following:



That s/he performed the service or was

physically present during the

key or critical portions

of the service when performed by the resident;

AND



The

participation

of the teaching physician in the management of the

patient.

Example: ‘I saw and examined the patient and agree with the resident’s

note…’

Time Based E/M Services:

The TP must be present and document for

the period of time for which the claim is made. Examples :



Critical Care, Hospital Discharge (>30 minutes) or



E/M codes where

more than 50% of the TP time spent counseling or

coordinating care



Psychotherapy

Medical Student documentation for billing only counts for ROS and

PFSH

Teaching Physicians and Mental Health



When psychiatric services are furnished under an approved

AC-GME program, the requirement for the presence of the teaching

physician during the service may be met by:



Concurrent observation of the service by use of a one-way

mirror or video equipment.



Note the following:



Audio-only equipment does not meet this exception to the

physical presence requirement.



In the case of time-based services such as individual

medical psychotherapy, the teaching physician must be

present throughout the session



Medicare teaching physician policy does not apply to

psychologists who supervise psychiatry residents in

Unacceptable TP Documentation



Assessed and Agree



Reviewed and Agree



Co-signed Note



Patient seen and examined and I agree with

the note



As documented by resident, I agree with the

history, exam and assessment/plan

Psychiatric Diagnostic Evaluation CPT 90791

& With Medical Evaluation CPT 90792

These codes require the same documentation as the previous

Psychiatric Diagnostic Interview codes (90801- 90802)



A psychiatric diagnostic evaluation is performed,

which includes the assessment of the patient's

psychosocial history, current mental status, review,

and ordering of diagnostic studies followed by

appropriate treatment recommendations. In 90792,

additional medical services such as physical

examination and prescription of pharmaceuticals are

provided in addition to the diagnostic evaluation.

Interviews and communication with family members

or other sources are included in these codes.

Psychiatric Diagnostic Evaluation CPT 90791

With Medical Evaluation CPT 90792

The evaluation must include

 Name of beneficiary and date of service  Reason for referral / presenting problem  Prior psychological history, including

therapy

 Other pertinent medical, social and family

history

 Clinical observations and mental status

examination

 Present evaluation  Diagnosis

 Recommendations

 Identity of provider of service

The evaluation may include

 Communication with family or

other sources,

 Ordering and medical

interpretation of laboratory tests and other medical

diagnostic studies, as appropriate.

 Use of interactive tools or

Common Coding Questions

1. Directions for billing when a patient is admitted to the Psych

Facility and then develops a medical problem requiring discharge

from the unit and admission to the medical unit.

2. Directions for billing when a patient is initially seen in the medical

hospital as a Consultation, who is later discharged from the

medical hospital and admitted to a Psych Facility.

Medicare Claims Processing (PUB. 100-04) Manual History

Chapter 12 30 - Correct Coding Policy 30.6.9.1 - Payment for

Initial Hospital Care

D - Physician Services Involving Transfer From One Hospital

to Another; Transfer Within Facility to Prospective Payment

System (PPS) Exempt Unit of Hospital; Transfer From One

Facility to Another Separate Entity Under Same Ownership

Common Coding Questions

Physicians may bill both the hospital discharge management code and

an initial hospital care code when the discharge and admission do not

occur on the same day if the transfer is between:

1.

Different hospitals;

2. Different facilities under common ownership which do not have

merged records; or

3. Between the acute care hospital and a PPS exempt unit within the

same hospital when there are no merged records.

In all other transfer circumstances, the physician should bill only

the appropriate level of subsequent hospital care for the date of

transfer.

Individual Psychotherapy

Psychotherapy codes are no longer site specific

Psychotherapy time includes face-to-face time spent with the patient and/or family member

Interactive psychotherapy is reported using the appropriate psychotherapy code along with the interactive complexity add-on code

• 90832, Psychotherapy, 30 minutes • 90834, Psychotherapy, 45 minutes • 90837, Psychotherapy, 60 minutes

• 90832 plus 90875, Psychotherapy, 30 minutes with interactive complexity add-on

• 90834 plus 90875, Psychotherapy, 45 minutes with interactive complexity add-on

Psychotherapy with E/M Services

47

Psychotherapy with E/M is now reported by selecting the appropriate E/M

service code (

99xxx series) and the appropriate psychotherapy add-on

code

•

The E/M code is selected on the basis of the site of service and the key

elements performed

•

The psychotherapy add-on code is selected on the basis of the time

spent providing psychotherapy and does not include any of the time

spent providing E/M services

•

If no E/M services are provided, use the appropriate psychotherapy code

(

90832, 90834, 90837)

E/M Services with Psychotherapy

48

If Psychotherapy is provided in addition to the E/M use the

Psychotherapy add-on codes

The psychotherapy add-on codes +90833 (30 min.), +90836 (45 min.), or +90838(60 min.) can be billed with the following E/M codes:

Outpatient, established patient: • 99212 – 99215

Subsequent hospital care: • 99231 – 99233

Subsequent nursing facility care: • 99307 – 99310

Subsequent ALF care: • 99334 – 99337

Subsequent home care; • 99341 – 99345

If no E/M services are provided, use the appropriate psychotherapy code (90832, 90834, 90837)

Psychotherapy for Crisis

49

Crisis Psychotherapy

•

90839, Psychotherapy for crisis, first 60 minutes (30-74 minutes)

+90840, Psychotherapy for crisis each additional 30 minutes

Crisis Psychotherapy is “an urgent assessment and history of a

crisis state, a mental status exam, and a disposition. The

treatment includes psychotherapy, mobilization of resources

to defuse the crisis and restore safety, and implementation of

psychotherapeutic interventions to minimize the potential for

psychological trauma. The presenting problem is typically life

threatening or complex and requires immediate attention to a

patient in high distress.”

Pharmacologic Management

Psychiatrists should use the appropriate E/M service code

(

99xxx) to report Pharmacologic Management.

Physicians SHOULD NOT use this code

The add-on code

+ 90863 has been added to describe

pharmacologic management when performed by a prescribing

psychologist during the same session as the psychotherapy.

Electroconvulsive Therapy (ECT)

51

90870 Indications:

Major depressive episode and/or major depressive disorder that meet the criteria according to the DSM-IV.

• Depression with acute suicide risk, extreme agitation, or unresponsive to pharmacological therapy.

• Bipolar illness with either mania or depression where medications are ineffective or not tolerated, or severe mania presenting a safety risk to the patient or to others. • Intolerance to the side effects of antidepressant medication or to antidepressant or psychotropic medications that pose a particular medical risk.

• When rapid resolution of depression is necessary, e.g., the patient is acutely suicidal or physically compromised, and the time factor to achieve maximal

effectiveness of antidepressants or mood stabilizers places the patient at immediate risk to health or safety.

• Inability to medically tolerate maintenance medication. • Catatonia

• Acute schizophrenia, or severe, life-threatening psychoses, which have not responded to, or cannot be treated with short term, high dose tranquilization. • When continuation of ECT treatments is necessary to sustain remission or to sustain significant improvement.

Electroconvulsive Therapy (ECT)

52

prescribed and must meet the conditions stated in the “Indications and Limitations of Coverage and/or Medical Necessity” section of the LCD.

Any clinical history supporting the use of ECT needs to clearly document the medical reasonable and necessary conditions as described in the “indications and limitations” section on the policy

Documentation supporting the medical necessity of this procedure must be a part of and kept in the medical record. It must be available upon request. Failure to provide the required documentation will result in a denial of the claim(s).

Documentation should include, but is not limited to, the following: • History and Physical Examination.

• Medical record containing established psychiatric diagnosis according to the DSM-IV.

• Medical records containing the patient’s evaluation and management findings and treatments with relevant clinical signs, symptoms, and/or abnormal diagnostic/lab tests.

• The clinical record should further indicate changes/alterations and response or non-response to medical management or treatment of the patient’s condition and reflect the continued need and appropriateness of ECT based on psychiatrist’s

Electroconvulsive Therapy (ECT)

Documentation should include, but is not limited to, the following: • History and Physical Examination.

• Medical record containing established psychiatric diagnosis according to the DSM-IV.

• Medical records containing the patient’s evaluation and management findings and treatments with relevant clinical signs, symptoms, and/or abnormal

diagnostic/lab tests.

• The clinical record should further indicate changes/alterations and response or non-response to medical management or treatment of the patient’s condition and reflect the continued need and appropriateness of ECT based on psychiatrist’s ongoing assessment and mental status examination of the patient during the course of treatments.

• It is understood that any diagnostic and clinical information submitted and presented in the medical record must substantiate that the components of the procedure performed and billed were actually performed.

Electroconvulsive Therapy (ECT)

54

Utilization Guidelines

Tests for screening purposes that are performed in the absence of signs,

symptoms, complaints, or personal history of disease or injury will be

considered non-covered.

Exams required by insurance companies, business establishments,

government agencies, or other third parties, without rationale for necessity

will be denied.

Tests that are not reasonable and necessary for the diagnosis or treatment

of an illness or injury are not covered according to the statute.

Failure to provide documentation of the medical necessity of tests will

result in denial of claims.

Neuropsychological Testing

55

96118 NEUROPSYCHOLOGICAL TESTING (EG, HALSTEAD-REITAN

NEUROPSYCHOLOGICAL BATTERY, WECHSLER MEMORY SCALES AND WISCONSIN CARD SORTING TEST), PER HOUR OF THE PSYCHOLOGIST’S OR PHYSICIAN’S TIME, BOTH

FACE-TO-FACE TIME ADMINISTERING TESTS TO THE PATIENT AND TIME INTERPRETING THESE TEST RESULTS AND PREPARING THE REPORT

The psychological/neuropsychological testing codes should not be reported by the treating physician for only reading the testing report or explaining the results to the patient or family. Payment for these services is included in the payment for other services rendered to the patient, such as evaluation and management services. Psychological and neuropsychological testing codes should be reported by the

performing provider (i.e., clinical psychologist, neuropsychologist, or physician) who administered the test.

Testing conducted when no mental illness/disability is suspected would be

considered screening and would not be covered by Medicare. Non-specific behaviors that do not suggest the possibility of mental illness or disability are not an acceptable indication for testing.

Neuropsychological Testing

Documentation Requirements

The medical record must indicate testing is necessary as an aid in the diagnosis and therapeutic planning. The record must show the tests performed, scoring and interpretation, as well as the time involved for services that are time-based.

The medical record should include all of the following information: • Reason for referral.

• Tests administered, scoring/interpretation, and time involved. • Present evaluation.

• Diagnosis (or suspected diagnosis that was the basis for the testing if no mental/neurocognitive illness was found).

• Recommendations for interventions, if necessary. • Identity of person performing service.

Neuropsychological Testing

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Psychological testing/neuropsychological testing may require four (4) to six (6) hours to perform (including administration, scoring, and interpretation.) If the testing is done over several days, the testing time should be combined and reported all on the last date of service. Supporting documentation in the medical record must be present to justify the medical necessity and hours tested per patient per evaluation. If the testing time exceeds eight (8) hours, medical necessity for the extended testing should be documented in the report.

Use of such tests when mental or neurocognitive illness is not suspected would be a screening procedure not covered by Medicare. Each test performed must be medically necessary. Therefore, standardized batteries of tests are not acceptable unless each test in the battery is medically necessary.

Routine re-evaluation of chronically disabled patients that is not required for a diagnosis or continued treatment is not medically necessary.

2014 CPT Code Changes

Interprofessional consultations



New codes to report interprofessional (“doctor-to-doctor”)

telephone/Internet consulting.



Code 99446 is defined as an interprofessional

telephone/Internet assessment and management service

provided by a consultative physician, including a verbal and

written report to the patient’s treating/requesting physician

or other qualified health care professional, and involves 5 to

10 minutes of medical consultative discussion and review.



99447: 11 to 20 minutes of medical consultative discussion and review

99448: 21 to 30 minutes of medical consultative discussion and review

99449: 31 minutes or more of medical consultative discussion and

2014 CPT Code Changes

Interprofessional consultations



The services will typically be provided in complex and/or

urgent situations where a timely face-to-face service with the

consultant may not be possible. The written or verbal request,

its rationale, and the conclusion for telephone/Internet

advice by the treating/requesting physician or other qualified

health care professional should be documented in the

patient’s medical record.

•

Increased specificity of the ICD-10 codes requires more

detailed clinical documentation to code some diagnoses to

the highest level of specificity.



Coding and documentation go hand in hand



ICD-10 based on complete and accurate documentation,

even where it comes to right and left or episode of care.



ICD-10 should impact documentation as physicians are

required to support medical necessity using appropriate

diagnosis code—this is not an easy situation.

HIPAA

Final Reminders for All Staff,

Residents, Fellows or Students

 Health Insurance Portability and Accountability Act – HIPAA

 Protect the privacy of a patient’s personal health information

 Access information for business purposes only and only the records you

need to complete your work.

 Notify Office of HIPAA Privacy and Security at 305-243-5000 if you

become aware of a potential or actual inappropriate use or disclosure of PHI, including the sharing of user names or passwords.

 PHI is protected even after a patient’s death!!!



Never share your password with anyone and no one use someone

else’s password for any reason, ever –even if instructed to do so.

Available Resources at University of Miami,

UHealth and the Miller School of Medicine



If you have any questions or concern regarding coding, billing,

documentation, and regulatory requirements issues, please contact:

 Gemma Romillo, Assistant Vice President of Clinical Billing

Compliance and HIPAA Privacy; or

 Iliana De La Cruz, RMC, Director Office of Billing Compliance

 Phone: (305) 243-5842



Officeofbillingcompliance@med.miami.edu



Also available is The University’s fraud and compliance hotline via the

web at www.canewatch.ethicspoint.com or

toll-free at 877-415-4357 (24hours a day, seven days a week).